FOR DGNM STUDENTS

1. Infertility

2. DEFINITION
Infertility is “a disease of the reproductive system
defined by the failure to achieve a clinical pregnancy
after 12 months or more of regular unprotected
sexual intercourse .There are two kinds of infertility –
primary and secondary:

3. TYPES OF INFERTILITY
 Primary infertility means that the couple has never conceived.
 Secondary infertility means that the couple has experienced a
pregnancy before and failed to conceive later. Globally, most
infertile couples suffer from primary infertility.
 Sexually transmitted infections (STIs) are the leading
preventable cause of infertility by causing 70% of pelvic
inflammatory diseases responsible for tubal damage. Low
fertility is becoming more common worldwide, particularly in
many urban settings where women are planning their first
babies at older ages.

4. Symptoms
For a woman, infertility (or a state of subfertility) can manifest
itself as either (WHO):
 the inability to become pregnant
 an inability to maintain a pregnancy
 an inability to carry a pregnancy to a live birth.

5. Causes
Infertility can be caused by both men and women factors. About a third of infertility problems
are due to female infertility and another third are due to male infertility
Female infertility can be caused by a number of factors:
 (a)Damage to fallopian tubes: Damage to the fallopian tubes (carry the eggs from the
ovaries to the uterus) can prevent contact between the egg and sperm. Pelvic inflammatory
diseases (PID)
 (b)Disturb ovarian function/hormonal causes: Synchronized hormonal changes occur
during the menstrual cycle
 Polycystic ovary syndrome(PCOS) Polycystic ovary syndrome is the common cause of
female infertility. PCOS interferes with normal ovulation.
 Functional hypothalamic amenorrhea: Excessive physical (common in athletes) or
emotional stress may result in amenorrhoea (absence of periods).

6. CONT….
 Diminished ovarian reserve or premature ovarian aging: women with
diminished ovarian reserve may experience difficulty in conceiving, (though blood
test will show elevated follicular stimulating hormones).
 Premature ovarian insufficiency: Female ovaries stop working before she is 40
years of age. The cause can be natural or it can be a disease, surgery,
chemotherapy, or radiation.
 (c)Uterine causes: Abnormal anatomy of the uterus; the presence of polyps and
fibroids may lead to infertility.
 (d)Cervical causes: A small group of women may have a cervical condition in
which the sperm cannot pass through the cervical canal due to abnormal mucus
production or a prior cervical surgical procedure.

7. Male factors causing infertility
More than 90% of male infertility cases are due to low sperm counts, poor sperm
quality, or both. The remaining cases of male infertility can be caused by number of
factors including anatomical problems, hormonal imbalances, and genetic defects.
Sperm abnormalities include:
 Oligospermia (low sperm counts) /Azoospermia (no sperms): sperm count
less than 20 million/ml is termed as oligospermia whereas azoospermia refers to
the complete absence of sperm cells in the ejaculate.
 Asthenospermia (Poor sperm motility): If 60% or more sperms have
abnormal motility (movement is slow and not in straight line) it is termed as
asthenospermia and may cause infertility.
 Teratospermia (abnormal sperm morphology): about 60% of the sperms
should be normal in size and shape for adequate fertility.

8. Factors that affect the fertility of both
sexes
 Environmental/occupational factors
 Toxic effects related to tobacco, marijuana, or other drugs
 Excessive exercise
 Inadequate diet associated with extreme weight loss or gain
 Advanced age

9. Diagnosis
Both male and female factors can contribute to infertility. A detailed medical history,
physical examination and investigations are needed to assess the cause of infertility.
 History taking: Couples with infertility problem are interviewed separately as
well as together to know about important facts with full history taking.
 (b)Clinical examination: Full clinical examination of both partners is required for
detection of any physical problem.
 (c) Investigations: Infertile couples are usually advised to start their investigations
after 12 months of trying to conceive or after six months if the female partner is
more than 35 years old or immediately if there is an obvious cause for their
infertility or subfertility.

10. CONT…….
 Semen analysis: It should be done after 72 hours of sexual abstinence and two analysis should
be advised with 3 months apart at the same lab.
Female partner
 Detection of ovarian function:
 Hormonal assay (early follicular FSH and LH levels, and mid-luteal progesterone levels),
 Transvaginal ultrasonography
 Evaluation of tubal patency:
 Hysterosalpingography (HSG)
Advanced investigations-
 Hormonal assay:
 Laparoscopy
 Hysteroscopy
 Chromosomal karyotyping

11. CONT……
Male partner-
Hormonal assay: FSH, LH, Testosterone, TSH and Prolactin
(for male with abnormal seminal analysis and suspected
endocrine disorder)
Testicular biopsy: A fine-needle aspiration biopsy to
differentiate between obstructive and non-obstructive
azoospermia.
Chromosomal karyotyping

12. Management
Management of infertility ranges from counseling and advice to medications and surgery.
 Healthy eating habits-
 Adding more whole-grain products, fruits, vegetables.
 Limiting processed foods and foods with added sugars, eating a diet low in cholesterol and
saturated fats
 Promote regular exercise
 No smoking (avoid passive smoking)
 Limit alcohol intake
 Maintain healthy weight
 Folic acid supplementation in women
 Advice on rubella vaccination if sero negative
 Treatment of Psycho-sexual problems

13. Assisted reproduction techniques (ART):
 Intrauterine insemination (IUI): IUI is the placement of a man’s
sperm into a woman’s uterus using a long, narrow tube. IUI may be
used in the following conditions.
 Defects of cervix
 Low sperm counts
 Sperm with low motility
 Erection problems in male partner
 Retrograde ejaculation (a condition in which sperms are deposited
in to the bladder instead of going out through the urethra)
 Women who have scarring or defects of the cervix.

14. CONT…
 In vitro fertilization (IVF): In vitro fertilization, eggs and sperm are taken from
the couple and are incubated together in a dish in a laboratory to produce an
embryo. Medical specialist places the embryo into the woman’s uterus, where it
may implant and develop in a successful pregnancy.
 Gamete intrafallopian transfer (GIFT): in this procedure fertilization occurs
naturally after eggs and sperm are placed inside the fallopian tube.
 Zygote intrafallopian transfer (ZIFT): In ZIFT fertilized eggs are transferred to
fallopian tube within 24 hours after fertilization.
 Intracytoplasmic sperm injection (ICSI): In this procedure single sperm is
injected in to mature egg. It is used to treat sperm related infertility problems.

15. Surrogate and gestational carriers-
If a woman is unable to carry a pregnancy to term, the couple may
choose a surrogate or gestational carrier.
 A surrogate is a woman inseminated with sperm from the male
partner of the couple. The resulting child will be biologically related
to the surrogate and to the male partner. Surrogacy can be used
when the female of the couple does not produce healthy eggs that
can be fertilized.
 A gestational carrier is implanted with an embryo that is not
biologically related to her. This alternative can be used when a
female partner produces healthy eggs but is unable to carry a
pregnancy to term. Egg or sperm donation can be used in this
situation.

16. Prevention
 Weight management is important in preventing and treating infertility
 Eat a balanced diet which should include whole grains, pulses, fresh
fruits and vegetables, low fat milk products.
 Participating in moderate exercise can help improve menstrual
regularities and overall health.
 Making time for leisure and enjoyment is a healthy step to lower stress
levels and improves physical and emotional health.
 Illegal drugs such as cocaine should be avoided as can affect fertility.
 Age and fertility- The decision to have a baby and determining the
right time to start a family is a highly personal choice.